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Munzen ME, Reguera Gomez M, Hamed MF, Enriquez V, Charles-Niño CL, Dores MR, Alviña K, Martinez LR. Palmitoylethanolamide shows limited efficacy in controlling cerebral cryptococcosis in vivo. Antimicrob Agents Chemother 2023; 67:e0045923. [PMID: 37750714 PMCID: PMC10583666 DOI: 10.1128/aac.00459-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/13/2023] [Indexed: 09/27/2023] Open
Abstract
Cryptococcus neoformans (Cn) is an encapsulated neurotropic fungal pathogen and the causative agent of cryptococcal meningoencephalitis (CME) in humans. Recommended treatment for CME is Amphotericin B (AmpB) and 5-fluorocytosine (5-FC). Though effective, AmpB has displayed numerous adverse side effects due to its potency and nephrotoxicity, prompting investigation into alternative treatments. Palmitoylethanolamide (PEA) is an immunomodulatory compound capable of promoting neuroprotection and reducing inflammation. To investigate the efficacy of PEA as a therapeutic alternative for CME, we intracerebrally infected mice with Cn and treated them with PEA or AmpB alone or in combination. Our results demonstrate that PEA alone does not significantly prolong survival nor reduce fungal burden, but when combined with AmpB, PEA exerts an additive effect and promotes both survivability and fungal clearance. However, we compared this combination to traditional AmpB and 5-FC treatment in a survivability study and observed lower efficacy. Overall, our study revealed that PEA alone is not effective as an antifungal agent in the treatment of CME. Importantly, we describe the therapeutic capability of PEA in the context of Cn infection and show that its immunomodulatory properties may confer limited protection when combined with an effective fungicidal agent.
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Affiliation(s)
- Melissa E. Munzen
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Marta Reguera Gomez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Mohamed F. Hamed
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
- Department of Pathology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Vanessa Enriquez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Claudia L. Charles-Niño
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Michael R. Dores
- Department of Biology, Hofstra University, Hempstead, New York, USA
| | - Karina Alviña
- Department of Neuroscience, University of Florida, Gainesville, Florida, USA
- Center for Translational Research in Neurodegenerative Disease, Gainesville, Florida, USA
| | - Luis R. Martinez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, USA
- Center for Translational Research in Neurodegenerative Disease, Gainesville, Florida, USA
- Center for Immunology and Transplantation, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
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Kang H, Uy JP, Ho CC, Blunt HB, Riblet NB, Pasqualotto AC, Murphy RA. Safety of Single High-Dose Liposomal Amphotericin B for Induction Treatment of Cryptococcal Meningitis and Histoplasmosis in People With HIV: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2023; 10:ofad472. [PMID: 37808894 PMCID: PMC10551850 DOI: 10.1093/ofid/ofad472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
Background Evidence for efficacy of single, high-dose liposomal amphotericin B (LAmB) in HIV-associated cryptococcal meningitis and histoplasmosis is growing. No systematic review has examined the safety of this regimen across multiple studies. Methods We systematically searched Medline, Scopus, and the Cochrane Library from inception to April 2023 for studies reporting grade 3 and 4 adverse events (AEs) with single high-dose LAmB vs traditional amphotericin regimens for HIV-associated fungal infections. Results Three trials (n = 946) were included. Compared with traditional regimens, single high-dose LAmB was associated with equivalent risk of grade 3 and 4 AEs (risk ratio [RR], 0.75; 95% CI, 0.53-1.06) and lower overall risk of grade 4 AEs (RR, 0.68; 95% CI, 0.55-0.86), grade 4 renal (RR, 0.43; 95% CI, 0.20-0.94) and grade 4 hematological AEs (RR, 0.46; 95% CI, 0.32-0.65). Conclusions Single, high-dose LAmB is associated with a lower risk of life-threatening AEs compared with other World Health Organization-endorsed amphotericin B-based regimens in invasive HIV-related fungal infection.
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Affiliation(s)
- HeeEun Kang
- Infectious Disease and International Health, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - John P Uy
- Infectious Disease and International Health, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Caroline C Ho
- Infectious Disease and International Health, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Heather B Blunt
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Natalie B Riblet
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Alessandro C Pasqualotto
- Infectious Diseases, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Richard A Murphy
- Infectious Disease and International Health, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- White River Junction VA Medical Center, Hartford, Vermont, USA
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Link A, Okwir M, Iribarren S, Meya D, Bohjanen PR, Kasprzyk D. Lack of education, knowledge, and supplies are barriers to cryptococcal meningitis care among nurses and other healthcare providers in rural Uganda: A mixed methods study. NURSE EDUCATION TODAY 2023; 128:105873. [PMID: 37390523 PMCID: PMC11138314 DOI: 10.1016/j.nedt.2023.105873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Cryptococcal meningitis (CM) is one of the deadliest opportunistic infections related to HIV/AIDS. A research gap exists surrounding the barriers to CM diagnosis, treatment delivery, and care from the healthcare provider's perspective. OBJECTIVES The purpose of this study was to elucidate provider's behaviors, to identify barriers and facilitators to diagnose and treat CM, and to assess their knowledge of CM, cryptococcal screening, and treatment. DESIGN, SETTING, AND PARTICIPANTS A convergent mixed-methods study among twenty healthcare providers who provided CM patient referrals to Lira Regional Referral Hospital in Lira, Uganda. METHODS Surveys and interviews were conducted to obtain information from healthcare providers who referred CM patients to Lira Regional Referral Hospital from 2017 to 2019. Questions related to provider education, knowledge, barriers to CM care, and patient education were inquired to understand the providers' perspectives. RESULTS Nurses had the least amount of CM knowledge with half knowing the cause of CM. Approximately half the participants knew about CM transmission, but only 15 % knew the duration of CM maintenance therapy. Most participants (74 %) last had education regarding CM during didactic training. In addition, 25 % disclosed they never educate patients due to time constraints (30 %) and lack of knowledge (30 %). Nurses (75 %) were least likely to provide patient education. Most participants acknowledged their lack of CM knowledge and attributed it to a lack of education and perceived inexperience with CM. CONCLUSIONS Providers' gaps in knowledge due to the lack of education and experience contributes to decreased patient education, and the lack of access to appropriate supplies affects their provision for CM diagnosis, treatment, and care. These results can guide evidence-based interventions to improve health providers' knowledge. Recommendations for standardized CM education should be developed for both providers and patients in collaboration with professional boards and the Uganda Ministry of Health.
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Affiliation(s)
- Abigail Link
- Center for Global Health and Social Responsibility, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Infectious Diseases, University of Rochester, Rochester, NY, USA.
| | - Mark Okwir
- Department of Internal Medicine, Lira Regional Referral Hospital, Faculty of Health Sciences, Lira University, Lira, Uganda
| | - Sarah Iribarren
- School of Nursing, University of Washington, Seattle, WA, USA.
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Paul R Bohjanen
- Division of Infectious Disease and International Medicine, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Infectious Diseases, University of Rochester, Rochester, NY, USA.
| | - Danuta Kasprzyk
- School of Nursing, University of Washington, Seattle, WA, USA.
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Kumari R, Talawar P, Tripaty DK, Singla D, Kaushal A, Sharma S, Malhotra M, Boruah P, Sangadala P, Kumar KS. A Retrospective Study to Evaluate the Perioperative Clinical Characteristics and Outcomes of Rhino-Orbital Cerebral Mucormycosis in COVID-19 Patients at a Tertiary Care Hospital in India. Cureus 2023; 15:e41613. [PMID: 37565105 PMCID: PMC10410089 DOI: 10.7759/cureus.41613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Background and aims A descriptive analysis of patients who underwent surgical debridement for coronavirus disease 2019 (COVID-19) related mucormycosis was described, which aimed at the evaluation of perioperative clinical characteristics, perioperative complications, and outcomes. Methods We conducted a retrospective study on patients who underwent surgical intervention for mucormycosis during the COVID-19 pandemic at a tertiary care institute in India from March 1, 2021, to June 30, 2021. The medical records of 92 patients were reviewed and analyzed. Results There was a male predominance with a mean age of 50.86 years. The most common comorbidity was diabetes mellitus (DM) (98.9%). Intra-operative complications included hypotension, hyperglycemia, and hypokalemia. Most of the patients (88%) were extubated inside the operation theater, and 48% of patients had mortality. Serum ferritin levels, computed tomography severity score (CTSS), and D-dimers were significantly high in the patient who had mortality. Conclusion The perioperative mortality in patients with COVID-19 associated mucormycosis was very high. DM was the most common comorbidity followed by hypertension. Pre-operative elevated serum ferritin, D-dimer, and high CTSS were associated with higher mortality; hypokalemia, followed by hypocalcemia, was the most common perioperative and post-operative electrolyte imbalance. Thorough pre-operative optimization, multidisciplinary involvement, and perioperative care are of the utmost importance to decrease mortality and improve outcomes.
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Affiliation(s)
- Rekha Kumari
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Praveen Talawar
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Debendra K Tripaty
- Anaesthesiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Deepak Singla
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ashutosh Kaushal
- Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Sameer Sharma
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Manu Malhotra
- Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Priyanka Boruah
- Anaesthesiology, State Cancer Institute, Guwahati, Guwahati, IND
| | - Priyanka Sangadala
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Karthikeyan S Kumar
- Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Munzen ME, Reguera-Gomez M, Hamed MF, Enriquez V, Charles-Nino CL, Dores MR, Alviña K, Martinez LR. Palmitoylethanolamide shows limited efficacy in controlling cerebral cryptococcosis in vivo. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.10.536237. [PMID: 37090670 PMCID: PMC10120726 DOI: 10.1101/2023.04.10.536237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Cryptococcus neoformans ( Cn ) is an encapsulated neurotropic fungal pathogen and the causative agent of cryptococcal meningoencephalitis (CME) in humans. Recommended treatment for CME is Amphotericin B (AmpB) and 5-fluorocytosine (5-FC). Though effective, AmpB has displayed numerous adverse side effects due to its potency and nephrotoxicity, prompting investigation into alternative treatments. Palmitoylethanolamide (PEA) is an immunomodulatory compound capable of promoting neuroprotection and reducing inflammation. To investigate the efficacy of PEA as a therapeutic alternative for CME, we intracerebrally infected mice with Cn and treated them with PEA or AmpB alone or in combination. Our results demonstrate that PEA alone does not significantly prolong survival nor reduce fungal burden, but when combined with AmpB, PEA exerts an additive effect and promotes both survivability and fungal clearance. However, we compared this combination to traditional AmpB and 5-FC treatment in a survivability study and observed lower efficacy. Overall, our study revealed that PEA alone is not effective as an antifungal agent in the treatment of CME. Importantly, we describe the therapeutic capability of PEA in the context of Cn infection and show that its immunomodulatory properties may confer limited protection when combined with an effective fungicidal agent.
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Affiliation(s)
- Melissa E. Munzen
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Marta Reguera-Gomez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Mohamed F. Hamed
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
- Department of Pathology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Vanessa Enriquez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Claudia L. Charles-Nino
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
| | | | - Karina Alviña
- Department of Neuroscience, University of Florida, Gainesville, FL, USA
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, USA
| | - Luis R. Martinez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, USA
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, USA
- Center for Immunology and Transplantation, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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Muzazu SGY, Assefa DG, Phiri C, Getinet T, Solomon S, Yismaw G, Manyazewal T. Prevalence of cryptococcal meningitis among people living with human immuno-deficiency virus and predictors of mortality in adults on induction therapy in Africa: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:989265. [PMID: 36160163 PMCID: PMC9494297 DOI: 10.3389/fmed.2022.989265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcal meningitis (CM) is a leading cause of adult meningitis in countries with a high burden of HIV. It has remained a significant cause of morbidity and mortality in Africa despite the extensive rollout of HIV antiretroviral therapy (ART). This study aimed to systematically synthesize the evidence on the prevalence of CM among people living with HIV (PLWH) and its predictors of mortality among adults who are on induction antifungal therapy in Africa. Methods PubMed/MEDLINE, Embase, and Google Scholar were searched for randomized clinical trials or observational studies published in Africa from 1995 to April 2021. Pooled prevalence of CM among PLWH was calculated using R-studio Version 1.4.1717 software and the data extracted from eligible studies were pooled as percentage with a 95% confidence interval (CI). Predictors of mortality among adults on induction antifungal therapy were synthesized narratively. Results Out of 364 studies identified, 17 eligible articles were included in the analysis. The prevalence of CM among PLWH in Africa was 5.11% (95% CI 2.71-9.43%; participants = 10,813; studies = 9; I 2 = 97%). In the subgroup analysis, the prevalence was 12.9% (95% CI 4.883-30.0; participants = 533; studies = 3; I 2 = 63%) in the years 1995-2010 and 3.18% (95% CI 1.54-6.45; participants = 10,280; studies = 6; I 2 = 98%) in the years 2011-2021, with the prevalence significantly decreased by 51% (p = 0.02). Predictors of mortality were fluconazole monotherapy, focal neurological signs, low Glasgow coma scale, and delayed diagnosis of CM at varied timepoint. Conclusion Prevalence of CM has significantly decreased from 1996-2010 to 2011-2021 among PLWH on induction therapy in Africa. Fluconazole monotherapy, focal neurological symptoms, diastolic blood pressure < 60 mmHg, and concurrent tuberculosis coinfection were significant predictors of mortality at 2- and 10-weeks timepoints. CM remains a major concern among PLWH despite increases in ART coverage. Improved access to effective antifungal therapies is needed in Africa for timely initiation of combination induction therapy and better treatment outcomes of PLWH. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254113], identifier [CRD42021254113].
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Affiliation(s)
- Seke G. Y. Muzazu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Enteric Diseases and Vaccines Research Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Dawit Getachew Assefa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Christabel Phiri
- Levy Mwanawasa University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Tewodros Getinet
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Gizachew Yismaw
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Case report: Disseminated cryptococcus gattii in an immunocompetent patient. IDCases 2022; 29:e01537. [PMID: 35761795 PMCID: PMC9233227 DOI: 10.1016/j.idcr.2022.e01537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
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Impact of a Cryptococcal meningitis diagnosis and treatment program at Lira Regional Referral Hospital in rural, Northern Uganda. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000254. [PMID: 36713975 PMCID: PMC9878995 DOI: 10.1371/journal.pgph.0000254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In rural areas of sub-Saharan Africa, infrastructure and resources for treatment of cryptococcal meningitis (CM) are often lacking. We introduced a CM diagnosis and treatment program (CM-DTP) at Lira Regional Referral Hospital (LRRH) in rural Uganda to determine if implementing high-quality standard of care protocols would improve outcomes. Information extracted from hospital charts and clinical record forms at LRRH were used to compare diagnoses, treatments, and outcomes for all patients diagnosed with meningitis (n = 281) over a two-year period after initiation of the CM-DTP in February of 2017 to all patients diagnosed with meningitis (n = 215) in the two preceding years. After implementation of the CM-DTP, we observed increased confirmed diagnoses of CM from 22.2% (48 of 215) to 35.2% (99 of 281), (p = 0.002) among all patients diagnosed with meningitis. Among all patients treated for CM, the proportion who received standard of care treatment with amphotericin B plus fluconazole increased from 63 of 127 (49.6%) to 109 of 146 (74.7%), (p <0.001) and mortality improved from 66 of 127 (52.0%) to 57 of 146 (39.0%), (p = 0.04) after implementation of the CM-DTP. Implementation of the CM-DTP was associated with increased number of lumbar punctures and decreased use of antibiotics in patients with CM, as well as decreased mortality among patients with meningitis from all causes. Improved diagnosis, treatment, and mortality were observed following implementation of the CM-DTP. Our results demonstrate that quality treatment of CM in rural Uganda is feasible.
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Bremer M, Kadernani YE, Wasserman S, Wilkinson RJ, Davis AG. Strategies for the diagnosis and management of meningitis in HIV-infected adults in resource limited settings. Expert Opin Pharmacother 2021; 22:2053-2070. [PMID: 34154509 DOI: 10.1080/14656566.2021.1940954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The incidence of human immunodeficiency virus-1 (HIV-1) associated meningitis has been declining in the post-combination antiretroviral treatment (ART) era, although survival rates remain low for the common causes like tuberculosis and cryptococcal disease. Diagnosis and treatment of meningitis in HIV-1 is complicated by atypical clinical presentations, limited accuracy of diagnostic tests, access to diagnostic tests, and therapeutic agents in low- and middle-income countries (LMIC) and immune reconstitution inflammatory syndrome (IRIS). AREAS COVERED We provide an overview of the common etiologies of meningitis in HIV-1-infected adults, suggest a diagnostic approach based on readily available tests, and review specific chemotherapeutic agents, host-directed therapies, supportive care, timing of ART initiation, and considerations in the management of IRIS with a focus on resource-limited settings. They identify key knowledge gaps and suggest areas for future research. EXPERT OPINION Evidence-based management of HIV-1-associated meningitis is sparse for common etiologies. More readily available and sensitive diagnostic tests as well as standardized investigation strategies are required in LMIC. There is a lack of availability of recommended drugs in areas of high HIV-1 prevalence and a limited pipeline of novel chemotherapeutic agents. Host-directed therapies have been inadequately studied.
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Affiliation(s)
- Marise Bremer
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory
| | - Yakub E Kadernani
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory
| | - Sean Wasserman
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Republic of South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, London, UK.,Francis Crick Institute, London, UK.,Faculty of Life Sciences, University College London, London, UK
| | - Angharad G Davis
- Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory.,Francis Crick Institute, London, UK.,Faculty of Life Sciences, University College London, London, UK
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Lawrence DS, Leeme T, Mosepele M, Harrison TS, Seeley J, Jarvis JN. Equity in clinical trials for HIV-associated cryptococcal meningitis: A systematic review of global representation and inclusion of patients and researchers. PLoS Negl Trop Dis 2021; 15:e0009376. [PMID: 34043617 PMCID: PMC8158913 DOI: 10.1371/journal.pntd.0009376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background It is essential that clinical trial participants are representative of the population under investigation. Using HIV-associated cryptococcal meningitis (CM) as a case study, we conducted a systematic review of clinical trials to determine how inclusive and representative they were both in terms of the affected population and the involvement of local investigators. Methods We searched Medline, EMBASE, Cochrane, Africa-Wide, CINAHL Plus, and Web of Science. Data were extracted for 5 domains: study location and design, screening, participants, researchers, and funders. Data were summarised and compared over 3 time periods: pre-antiretroviral therapy (ART) (pre-2000), early ART (2000 to 2009), and established ART (post-2010) using chi-squared and chi-squared for trend. Comparisons were made with global disease burden estimates and a composite reference derived from observational studies. Results Thirty-nine trials published between 1990 and 2019 were included. Earlier studies were predominantly conducted in high-income countries (HICs) and recent studies in low- and middle-income countries (LMICs). Most recent studies occurred in high CM incidence countries, but some highly affected countries have not hosted trials. The sex and ART status of participants matched those of the general CM population. Patients with reduced consciousness and those suffering a CM relapse were underrepresented. Authorship had poor representation of women (29% of all authors), particularly as first and final authors. Compared to trials conducted in HICs, trials conducted in LMICs were more likely to include female authors (32% versus 20% p = 0.014) but less likely to have authors resident in (75% versus 100%, p < 0.001) or nationals (61% versus 93%, p < 0.001) of the trial location. Conclusions There has been a marked shift in CM trials over the course of the HIV epidemic. Trials are primarily performed in locations and populations that reflect the burden of disease, but severe and relapse cases are underrepresented. Most CM trials now take place in LMICs, but the research is primarily funded and led by individuals and institutions from HICs. It is essential that clinical trial participants are representative of the population under investigation. Similarly, research must meaningfully include researchers who are from and/or based in the location where the study is being conducted, both to ensure that the research matches the local need but also to promote equity in research. Using clinical trials in HIV-associated cryptococcal meningitis as a case study, we conducted a systematic review to determine how inclusive and representative trials have been across the course of the HIV epidemic. We identified 39 studies. There was a geographical shift with trials moving from the USA to Africa and Asia over time. We found that recent trials were conducted in areas heavily affected by cryptococcal meningitis, but we did identify geographical areas and patient groups that have been underrepresented. We also found inequality within authorship that was skewed towards male researchers from high-income countries. These findings outline areas for our discipline to focus on. We can also use this study as a benchmark from which to monitor our progress over time. This is a broad methodology that could be adopted and adapted by other research groups.
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Affiliation(s)
- David S. Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Tshepo Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- University of Botswana, Gaborone, Botswana
| | - Thomas S. Harrison
- Institute for Infection and Immunity, St George’s University of London, and St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Janet Seeley
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Warrell CE, Macrae C, McLean ARD, Wilkins E, Ashley EA, Smithuis F, Tun NN. Ambulatory induction phase treatment of cryptococcal meningitis in HIV integrated primary care clinics, Yangon, Myanmar. BMC Infect Dis 2021; 21:375. [PMID: 33882845 PMCID: PMC8059000 DOI: 10.1186/s12879-021-06049-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. Existing literature focusses on hospital-based outcomes of induction treatment. This paper reviews outpatient management in integrated primary care clinics in Yangon. METHOD This retrospective case note review analyses a Myanmar HIV-positive patient cohort managed using ambulatory induction-phase treatment with intravenous amphotericin-B-deoxycholate (0.7-1.0 mg/kg) and oral fluconazole (800 mg orally/day). RESULTS Seventy-six patients were diagnosed between 2010 and 2017. The median age of patients diagnosed was 35 years, 63% were male and 33 (45%) were on concurrent treatment for tuberculosis. The median CD4 count was 60 at the time of diagnosis. Amphotericin-B-deoxycholate infusions precipitated 56 episodes of toxicity, namely hypokalaemia, nephrotoxicity, anaemia, febrile reactions, phlebitis, observed in 44 patients (58%). One-year survival (86%) was higher than existing hospital-based treatment studies. CONCLUSION Ambulation of patients in this cohort saved 1029 hospital bed days and had better survival outcomes when compared to hospital-based studies in other resource constrained settings.
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Affiliation(s)
- Clare E Warrell
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar.
| | | | - Alistair R D McLean
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | | | - Elizabeth A Ashley
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Frank Smithuis
- Myanmar Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar
- Medical Action Myanmar, Yangon, Myanmar
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Ni Ni Tun
- Medical Action Myanmar, Yangon, Myanmar
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12
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Temfack E, Rim JJB, Spijker R, Loyse A, Chiller T, Pappas PG, Perfect J, Sorell TC, Harrison TS, Cohen JF, Lortholary O. Cryptococcal Antigen in Serum and Cerebrospinal Fluid for Detecting Cryptococcal Meningitis in Adults Living With Human Immunodeficiency Virus: Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies. Clin Infect Dis 2021; 72:1268-1278. [PMID: 32829406 PMCID: PMC8522332 DOI: 10.1093/cid/ciaa1243] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 02/01/2023] Open
Abstract
Cryptococcal antigen (CrAg) detection could direct the timely initiation of antifungal therapy. We searched MEDLINE and Embase for studies where CrAg detection in serum/cerebrospinal fluid (CSF) and CSF fungal culture were done on adults living with human immunodeficiency virus (HIV) who had suspected cryptococcal meningitis (CM). With Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2), we evaluated the risk of bias in 11 included studies with 3600 participants, and used a random-effects meta-analysis to obtain summary sensitivity and specificity of serum and CSF CrAg, as well as agreement between CSF CrAg and CSF culture. Summary sensitivity and specificity of serum CrAg were 99.7% (97.4-100) and 94.1% (88.3-98.1), respectively, and summary sensitivity and specificity of CSF CrAg were 98.8% (96.2-99.6) and 99.3% (96.7-99.9), respectively. Agreement between CSF CrAg and CSF culture was 98% (97-99). In adults living with HIV who have CM symptoms, serum CrAg negativity may rule out CM, while positivity should prompt induction antifungal therapy if lumbar puncture is not feasible. In a first episode of CM, CSF CrAg positivity is diagnostic.
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Affiliation(s)
- Elvis Temfack
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- Internal Medicine Unit, Douala General Hospital,
Douala, Cameroon
| | | | - Rene Spijker
- Cochrane Netherlands, Julius Centre for Health Sciences and Primary
Care, University Medical Centre Utrecht,
Utrecht, The
Netherlands
| | - Angela Loyse
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Tom Chiller
- Tulane School of Public Health and Tropical Medicine,
Atlanta, Georgia, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at
Birmingham, Birmingham, Alabama, USA
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke
University Medical Centre, Durham, North
Carolina, USA
| | - Tania C Sorell
- University of Sydney Faculty of Medicine and Health, Westmead Clinical
School and Centre for Infectious Diseases and Microbiology, The Westmead
Institute of Medical Research, Westmead,
Australia
| | - Thomas S Harrison
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Jérémie F Cohen
- Institut National de la Sante et de la Recherche Medicale UMR 1153
Hospital, Assistance Publique-Hopitaux de Paris, Paris Descartes
University, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases,
Necker Hospital, Assistance Publique-Hopitaux de Paris. Paris Descartes
University, Paris, France
| | - Olivier Lortholary
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- University Paris Descartes, Necker Pasteur Center for Infectious
Diseases and Tropical Medicine, Hôpital Necker - Enfants malades,
Assistance Publique-Hopitaux de Paris, Institut Hospitalo-Universitaire
Imagine, Paris, France
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13
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Miot J, Leong T, Takuva S, Parrish A, Dawood H. Cost-effectiveness analysis of flucytosine as induction therapy in the treatment of cryptococcal meningitis in HIV-infected adults in South Africa. BMC Health Serv Res 2021; 21:305. [PMID: 33823842 PMCID: PMC8025344 DOI: 10.1186/s12913-021-06268-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
Background Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135,000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa. Methods A decision analytic cost-effectiveness and cost impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered five treatment arms: (a) standard of care; 2-week course amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) (d) oral course; 2-week oral fluconazole/flucytosine (oral) and e) 1-week course amphotericin B/fluconazole (1wk AmBd/Flu). A sensitivity analysis was conducted on key variables. Results The highest total treatment costs are in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, the 1-week AmBd/5FC, then standard of care with the lowest cost in the 1-week AmBd/Flu arm. Compared to the lowest cost option the 1-week flucytosine course is most cost-effective at USD119/QALY. The cost impact analysis shows that the 1-week flucytosine course has an incremental cost of just over USD293 per patient per year compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to life expectancy and hospital costs, particularly infusion costs and length of stay. Conclusions The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective when it is used as a 1-week AmBd/5FC regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.
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Affiliation(s)
- Jacqui Miot
- Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Trudy Leong
- National Department of Health, Affordable Medicines Directorate, Essential Drugs Programme, Pretoria, South Africa
| | - Simbarashe Takuva
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Andrew Parrish
- Department of Internal Medicine, Cecilia Makiwane Hospital, East London, South Africa
| | - Halima Dawood
- Department of Medicine, Greys Hospital, Pietermaritzburg, KwaZulu-Natal, South Africa.,Caprisa, University of KwaZulu-Natal, Durban, South Africa
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14
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Naicker SD, Mpembe RS, Maphanga TG, Zulu TG, Desanto D, Wadula J, Mvelase N, Maluleka C, Reddy K, Dawood H, Maloba M, Govender NP. Decreasing fluconazole susceptibility of clinical South African Cryptococcus neoformans isolates over a decade. PLoS Negl Trop Dis 2020; 14:e0008137. [PMID: 32231354 PMCID: PMC7108701 DOI: 10.1371/journal.pntd.0008137] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023] Open
Abstract
Background Fluconazole is used in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. More than 90% of isolates from first episodes of cryptococcal disease had a fluconazole minimum inhibitory concentration (MIC) ≤4 μg/ml in a Gauteng population-based surveillance study of Cryptococcus neoformans in 2007–2008. We assessed whether fluconazole resistance had emerged in clinical cryptococcal isolates over a decade. Methodology and principal findings We prospectively collected C. neoformans isolates from 1 January through 31 March 2017 from persons with a first episode of culture-confirmed cryptococcal disease at 37 South African hospitals. Isolates were phenotypically confirmed to C. neoformans species-complex level. We determined fluconazole MICs (range: 0.125 μg/ml to 64 μg/ml) of 229 C. neoformans isolates using custom-made broth microdilution panels prepared, inoculated and read according to Clinical and Laboratory Standards Institute M27-A3 and M60 recommendations. These MIC values were compared to MICs of 249 isolates from earlier surveillance (2007–2008). Clinical data were collected from patients during both surveillance periods. There were more males (61% vs 39%) and more participants on combination induction antifungal treatment (92% vs 32%) in 2017 compared to 2007–2008. The fluconazole MIC50, MIC90 and geometric mean MIC was 4 μg/ml, 8 μg/ml and 4.11 μg/ml in 2017 (n = 229) compared to 1 μg/ml, 2 μg/ml and 2.08 μg/ml in 2007–2008 (n = 249) respectively. Voriconazole, itraconazole and posaconazole Etests were performed on 16 of 229 (7%) C. neoformans isolates with a fluconazole MIC value of ≥16 μg/ml; only one had MIC values of >32 μg/ml for these three antifungal agents. Conclusions and significance Fluconazole MIC50 and MIC90 values were two-fold higher in 2017 compared to 2007–2008. Although there are no breakpoints, higher fluconazole doses may be required to maintain efficacy of standard treatment regimens for cryptococcal meningitis. Cryptococcus neoformans, a pathogenic fungal species-complex with an environmental niche, is the most common cause of meningitis among HIV-seropositive adults in sub-Saharan Africa. Fluconazole is recommended in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. Fluconazole is also commonly prescribed to HIV-seropositive individuals for other indications; fluconazole exposure may result in secondary resistance if patients have concurrent active cryptococcal disease. Azole fungicides used in agriculture may potentially drive primary cryptococcal resistance when the fungus is exposed to these fungicides in the environment. We aimed to determine fluconazole MICs in 2017 and compare these values to those obtained in a 2007–2008 South African survey to assess whether fluconazole resistance had emerged in C. neoformans over a decade. We found that the proportion of isolates with an MIC of ≥16 μg/ml increased from 0% in 2007–2008 to 7% in 2017. MIC50 and MIC90 values were also two-fold higher in 2017 compared to 2007–2008. These study findings provided evidence for higher fluconazole dose recommendations (in combination with amphotericin B for the induction phase and as monotherapy for consolidation and maintenance phases) in the 2019 Southern African guideline for HIV-associated cryptococcosis.
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Affiliation(s)
- Serisha D. Naicker
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Ruth S. Mpembe
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Tsidiso G. Maphanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Thokozile G. Zulu
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Daniel Desanto
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeannette Wadula
- National Health Laboratory Service, Microbiology Laboratory, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Nomonde Mvelase
- National Health Laboratory Service, Department of Medical Microbiology, RK Khan Hospital, Durban, South Africa
| | - Caroline Maluleka
- National Health Laboratory Service, Microbiology Laboratory, Dr George Mukhari Academic Hospital, Pretoria, South Africa
| | - Kessendri Reddy
- National Health Laboratory Service, Microbiology Laboratory, Tygerberg Academic Hospital, Cape Town, South Africa
| | - Halima Dawood
- National Health Laboratory Service, Microbiology Laboratory, Edendale Hospital, Pietermaritzburg, South Africa
| | - Motlatji Maloba
- National Health Laboratory Service, Department of Medical Microbiology, Universitas Academic Laboratory Complex, Bloemfontein, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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15
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Tenforde MW, Gertz AM, Lawrence DS, Wills NK, Guthrie BL, Farquhar C, Jarvis JN. Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25416. [PMID: 31957332 PMCID: PMC6970088 DOI: 10.1002/jia2.25416] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.
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Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
| | - Alida M Gertz
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Nicola K Wills
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Welcome Centre for Infectious Diseases Research in AfricaInfectious Disease and Molecular Medicine UnitUniversity of Cape TownCape TownSouth Africa
| | - Brandon L Guthrie
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Carey Farquhar
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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16
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Pathways to care and outcomes among hospitalised HIV-seropositive persons with cryptococcal meningitis in South Africa. PLoS One 2019; 14:e0225742. [PMID: 31830060 PMCID: PMC6907845 DOI: 10.1371/journal.pone.0225742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction Cryptococcus causes 15% of AIDS-related deaths and in South Africa, with its high HIV burden, is the dominant cause of adult meningitis. Cryptococcal meningitis (CM) mortality is high, partly because patients enter care with advanced HIV disease and because of failure of integrated care following CM diagnosis. We evaluated pathways to hospital care, missed opportunities for HIV testing and initiation of care. Methods We performed a cross-sectional study at five public-sector urban hospitals. We enrolled adults admitted with a first or recurrent episode of cryptococcal meningitis. Study nurses conducted interviews, supplemented by a prospective review of medical charts and laboratory records. Results From May to October 2015, 102 participants were enrolled; median age was 40 years (interquartile range [IQR] 33.9–46.7) and 56 (55%) were male. In the six weeks prior to admission, 2/102 participants were asymptomatic, 72/100 participants sought care at a public-sector facility, 16/100 paid for private health care. The median time from seeking care to admission was 4 days (IQR, 0–27 days). Of 94 HIV-seropositive participants, only 62 (66%) knew their status and 41/62 (66%) had ever taken antiretroviral treatment. Among 13 participants with a known previous CM episode, none were taking fluconazole maintenance therapy. In-hospital management was mostly amphotericin B; in-hospital mortality was high (28/92, 30%). Sixty-four participants were discharged, 92% (59/64) on maintenance fluconazole, 4% (3/64) not on fluconazole and 3% (2/64) unknown. Twelve weeks post-discharge, 31/64 (48%) participants were lost to follow up. By 12 weeks post discharge 7/33 (21%) had died. Interviewed patients were asked if they were still on fluconazole, 11% (2/18) were not. Conclusions Among hospitalised participants with CM, there were many missed opportunities for HIV care and linkage to ART prior to admission. Universal reflex CrAg screening may prompt earlier diagnosis of cryptococcal meningitis but there is a wider problem of timely linkage to care for HIV-seropositive people.
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17
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Govender NP, Meintjes G, Mangena P, Nel J, Potgieter S, Reddy D, Rabie H, Wilson D, Black J, Boulware D, Boyles T, Chiller T, Dawood H, Dlamini S, Harrison TS, Ive P, Jarvis J, Karstaedt A, Madua MC, Menezes C, Moosa MYS, Motlekar Z, Shroufi A, Stacey SL, Tsitsi M, van Cutsem G, Variava E, Venter M, Wake R. Southern African HIV Clinicians Society guideline for the prevention, diagnosis and management of cryptococcal disease among HIV-infected persons: 2019 update. South Afr J HIV Med 2019; 20:1030. [PMID: 32201629 PMCID: PMC7081625 DOI: 10.4102/sajhivmed.v20i1.1030] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Nelesh P Govender
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phetho Mangena
- Department of Medicine, Polokwane Hospital, Polokwane, South Africa
| | - Jeremy Nel
- Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Samantha Potgieter
- Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
| | - Denasha Reddy
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Helena Rabie
- Department of Paediatrics, Tygerberg Hospital, Stellenbosch University, Stellenbosch, South Africa
| | - Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, Pietermaritzburg, South Africa
- School of Clinical Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Port Elizabeth, South Africa
| | - David Boulware
- Department of Medicine, Centre for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, United States
| | - Tom Boyles
- Anova Health Institute, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tom Chiller
- Mycotic Diseases Branch, US Centres for Disease Control and Prevention, Atlanta, United States
| | - Halima Dawood
- Department of Medicine, Grey's Hospital, Pietermaritzburg, South Africa
- Caprisa, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, Helen Joseph Hospital, Johannesburg, South Africa
| | - Joseph Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alan Karstaedt
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, Charlotte Maxeke Johannesburg Hospital, Johannesburg, South Africa
| | - Matamela C Madua
- Department of Medicine, Rob Ferreira Hospital, Mbombela, South Africa
| | - Colin Menezes
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mahomed-Yunus S Moosa
- Department of Infectious Diseases, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Zaaheera Motlekar
- Department of Medicine, Kimberley Provincial Hospital, Kimberley, South Africa
| | - Amir Shroufi
- Mycotic Diseases Branch, US Centres for Disease Control and Prevention, Atlanta, United States
| | - Sarah Lynn Stacey
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Merika Tsitsi
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gilles van Cutsem
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Ebrahim Variava
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Tshepong Hospital, Klerksdorp, South Africa
| | - Michelle Venter
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rachel Wake
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
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18
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Patel RKK, Leeme T, Azzo C, Tlhako N, Tsholo K, Tawanana EO, Molefi M, Mosepele M, Lawrence DS, Mokomane M, Tenforde MW, Jarvis JN. High Mortality in HIV-Associated Cryptococcal Meningitis Patients Treated With Amphotericin B-Based Therapy Under Routine Care Conditions in Africa. Open Forum Infect Dis 2018; 5:ofy267. [PMID: 30488038 PMCID: PMC6251350 DOI: 10.1093/ofid/ofy267] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/22/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) causes 10%-20% of HIV-related deaths in Africa. Due to limited access to liposomal amphotericin and flucytosine, most African treatment guidelines recommend amphotericin B deoxycholate (AmB-d) plus high-dose fluconazole; outcomes with this treatment regimen in routine care settings have not been well described. METHODS Electronic national death registry data and computerized medical records were used to retrospectively collect demographic, laboratory, and 1-year outcome data from all patients with CM between 2012 and 2014 at Botswana's main referral hospital, when recommended treatment for CM was AmB-d 1 mg/kg/d plus fluconazole 800 mg/d for 14 days. Cumulative survival was estimated at 2 weeks, 10 weeks, and 1 year. RESULTS There were 283 episodes of CM among 236 individuals; 69% (163/236) were male, and the median age was 36 years. All patients were HIV-infected, with a median CD4 count of 39 cells/mm3. Two hundred fifteen person-years of follow-up data were captured for the 236 CM patients. Complete outcome data were available for 233 patients (99%) at 2 weeks, 224 patients (95%) at 10 weeks, and 219 patients (93%) at 1 year. Cumulative mortality was 26% (95% confidence interval [CI], 20%-32%) at 2 weeks, 50% (95% CI, 43%-57%) at 10 weeks, and 65% (95% CI, 58%-71%) at 1 year. CONCLUSIONS Mortality rates following HIV-associated CM treated with AmB-d and fluconazole in a routine health care setting in Botswana were very high. The findings highlight the inadequacies of current antifungal treatments for HIV-associated CM and underscore the difficulties of administering and monitoring intravenous amphotericin B deoxycholate therapy in resource-poor settings.
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Affiliation(s)
- Raju K K Patel
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tshepo Leeme
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Caitlin Azzo
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Nametso Tlhako
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | - Katlego Tsholo
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | - Mosepele Mosepele
- University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Mark W Tenforde
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
| | - Joseph N Jarvis
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Eshun‐Wilson I, Okwen MP, Richardson M, Bicanic T. Early versus delayed antiretroviral treatment in HIV-positive people with cryptococcal meningitis. Cochrane Database Syst Rev 2018; 7:CD009012. [PMID: 30039850 PMCID: PMC6513637 DOI: 10.1002/14651858.cd009012.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND There remains uncertainty about the optimum timing of antiretroviral therapy (ART) initiation in HIV-positive people with cryptococcal meningitis. This uncertainty is the result of conflicting data on the mortality risk and occurrence of immune reconstitution inflammatory syndrome (IRIS) when ART is initiated less than four weeks after cryptococcal meningitis treatment is commenced. OBJECTIVES To compare the outcomes of early initiation of ART (less than four weeks after starting antifungal treatment) versus delayed initiation of ART (four weeks or more after starting antifungal treatment) in HIV-positive people with concurrent cryptococcal meningitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase for trials published between 1 January 1980 and 7 August 2017. We additionally searched international trial registries, including ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP), and conference abstracts from the International AIDS Society (IAS) and the Conference on Retroviruses and Opportunistic Infections (CROI) for ongoing or unpublished studies between 2015 and 2017. We reviewed reference lists of included studies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared early versus delayed ART initiation in HIV-positive people with cryptococcal meningitis. Children, adults, and adolescents from any setting were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria and extracted data. We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs). We presented time-to-death data as hazard ratios with 95% CIs. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Four trials including 294 adult participants met the inclusion criteria of this review. Participants were predominantly from low- and middle-income countries. Two trials treated cryptococcal meningitis with amphotericin B and fluconazole; a third trial used fluconazole monotherapy; and the fourth trial did not specify the antifungal used.Early ART initiation may increase all-cause mortality compared to delayed ART initiation (RR 1.42, 95% CI 1.02 to 1.97; 294 participants, 4 trials; low-certainty evidence). Early ART initiation may reduce relapse of cryptococcal meningitis compared to delayed ART initiation (RR 0.27, 95% CI 0.07 to 1.04; 205 participants, 2 trials, low-certainty evidence). We are uncertain whether early ART initiation increases or reduces cryptococcal IRIS events compared to delayed ART initiation (RR 3.56, 95% CI 0.51 to 25.02; 205 participants, 2 trials; I2 = 54%; very low-certainty evidence). We are uncertain if early ART initiation increases or reduces virological suppression at six months compared to delayed ART initiation (RR 0.93, 95% CI 0.72 to 1.22; 205 participants, 2 trials; I2 statistic = 0%; very low-certainty evidence).We were unable to pool results related to rate of fungal clearance for the two trials that reported this outcome; individual trial results indicated that there was no difference in cerebrospinal fluid fungal clearance between trial arms. Similarly, we were unable to pool results on adverse events for the trials reporting on this outcome; individual trial results indicated no difference in the occurrence of grade 3 to 5 adverse events between trial arms.Three of the four included trials had an overall low or unclear risk of bias related to the primary outcome of all-cause mortality. However, we assessed one trial as at high risk of bias due to selective outcome reporting and other bias. This, in addition to the few clinical events and imprecision of effect estimates, led to downgrading of the evidence to low or very low certainty. AUTHORS' CONCLUSIONS The results of this review are relevant to HIV-positive adults with cryptococcal meningitis in low- and middle-income countries. These data suggest a higher risk of mortality among people who initiate ART within four weeks of cryptococcal meningitis diagnosis. However, it is unclear if this higher mortality risk is related to cryptococcal meningitis-IRIS.
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Affiliation(s)
- Ingrid Eshun‐Wilson
- Stellenbosch UniversityCentre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health SciencesFrancie van Zyl Drive, Tygerberg, 7505, ParowCape TownWestern CapeSouth Africa7505
| | - Mbah P Okwen
- Yaoundé Central HospitalCentre for the Development of Best Practices in Health (CDBPH)YaoundéCameroon
| | - Marty Richardson
- Liverpool School of Tropical MedicineCochrane Infectious Diseases GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Tihana Bicanic
- St George's University of LondonInstitute of Infection and ImmunityLondonUK
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20
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Truong M, Monahan LG, Carter DA, Charles IG. Repurposing drugs to fast-track therapeutic agents for the treatment of cryptococcosis. PeerJ 2018; 6:e4761. [PMID: 29740519 PMCID: PMC5937474 DOI: 10.7717/peerj.4761] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/21/2018] [Indexed: 12/21/2022] Open
Abstract
Many infectious diseases disproportionately affect people in the developing world. Cryptococcal meningitis is one of the most common mycoses in HIV-AIDS patients, with the highest burden of disease in sub-Saharan Africa. Current best treatment regimens still result in unacceptably high mortality rates, and more effective antifungal agents are needed urgently. Drug development is hampered by the difficulty of developing effective antifungal agents that are not also toxic to human cells, and by a reluctance among pharmaceutical companies to invest in drugs that cannot guarantee a high financial return. Drug repurposing, where existing drugs are screened for alternative activities, is becoming an attractive approach in antimicrobial discovery programs, and various compound libraries are now commercially available. As these drugs have already undergone extensive optimisation and passed regulatory hurdles this can fast-track their progress to market for new uses. This study screened the Screen-Well Enzo library of 640 compounds for candidates that phenotypically inhibited the growth of Cryptococcus deuterogattii. The anthelminthic agent flubendazole, and L-type calcium channel blockers nifedipine, nisoldipine and felodipine, appeared particularly promising and were tested in additional strains and species. Flubendazole was very active against all pathogenic Cryptococcus species, with minimum inhibitory concentrations of 0.039-0.156 μg/mL, and was equally effective against isolates that were resistant to fluconazole. While nifedipine, nisoldipine and felodipine all inhibited Cryptococcus, nisoldipine was also effective against Candida, Saccharomyces and Aspergillus. This study validates repurposing as a rapid approach for finding new agents to treat neglected infectious diseases.
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Affiliation(s)
- Megan Truong
- The ithree institute, University of Technology Sydney, Sydney, NSW, Australia
| | - Leigh G Monahan
- The ithree institute, University of Technology Sydney, Sydney, NSW, Australia
| | - Dee A Carter
- School of Life and Environmental Sciences and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Ian G Charles
- The ithree institute, University of Technology Sydney, Sydney, NSW, Australia.,Quadram Institute Bioscience, Norwich Research Park, Norwich, United Kingdom
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21
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Mchiza ZJ, Parker WA, Sewpaul R, Job N, Chola L, Mutyambizi C, Sithole M, Stokes A, Labadarios D. Understanding the determinants of hemoglobin and iron status: adolescent-adult women comparisons in SANHANES-1. Ann N Y Acad Sci 2018; 1416:31-47. [PMID: 29359477 DOI: 10.1111/nyas.13528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/21/2017] [Accepted: 09/21/2017] [Indexed: 12/18/2022]
Abstract
The study compared hemoglobin (Hb) and serum ferritin levels between adolescent and adult women with different body mass indices, dietary intake, and sociodemography. A secondary analysis of data for 3177 South African women ⩾15 years of age who participated in the SANHANES-1 study was undertaken. Abnormal Hb (≤12 g/dL) and serum ferritin (<15 μg/mL) were based on the World Health Organization's criteria for nonpregnant women aged ⩾15 years. Data were analyzed using STATA version 11. Overall, anemia was detected in 740 (23.3%) participants. Of the individuals in the subsample (n = 1123, 15-35 years) who had serum ferritin measured, 6.0% presented with iron depletion (ID) and 10.8% presented with iron-deficiency anemia (IDA). The highest prevalences of anemia, ID, and IDA were in 15- to 18-year-olds (11.2%, 8.8%, and 20.2%, respectively). Black young adults (19-24 years) were up to 40 times more likely to present with ID compared with their non-black counterparts. While overweight adolescents were three times more likely to be anemic, overweight and obese young adults, as well as obese older adults (25-35 years), were less likely to be anemic compared with normal-weight women of all age groups. Overconsumption of dietary fat increased ID by up to 54- and 11-fold (adolescents and 25- to 35-year-olds, respectively). In South Africa, anemia is most prevalent in adolescents and black women. Anemia is also an indicator of overconsumption of dietary fat and a marker of socioeconomic disadvantage.
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Affiliation(s)
- Zandile J Mchiza
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Whadi-Ah Parker
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Ronel Sewpaul
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Nophiwe Job
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Lumbwe Chola
- PRICELESS SA, University of Witwatersr and School of Public Health, Parktown, South Africa
| | - Chipo Mutyambizi
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
| | - Moses Sithole
- Centre for Science, Technology and Innovation Indicators, Cape Town, South Africa
| | - Andrew Stokes
- Boston University School of Public Health, Boston, Massachusetts
| | - Demetre Labadarios
- Population Health, Health Systems and Innovation, Human Sciences Research Council, Cape Town, South Africa
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22
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Looking for fungi in all the right places: screening for cryptococcal disease and other AIDS-related mycoses among patients with advanced HIV disease. Curr Opin HIV AIDS 2017; 12:139-147. [PMID: 28134711 DOI: 10.1097/coh.0000000000000347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW As HIV treatment programmes scale up to meet the UNAIDS 90-90-90 goals, care must be taken to start antiretroviral treatment safely in patients with advanced disease (CD4 counts <200 cells/μl) who are simultaneously at risk for opportunistic infections and immune reconstitution inflammatory syndrome. Invasive fungal diseases pose a great threat at this critical time point, though the development of inexpensive and highly accurate rapid diagnostic tests has changed the approach HIV programmes are taking to reduce the high mortality associated with these opportunistic infections. This article summarizes recent advances and findings in fungal opportunistic infection diagnostics with a focus on screening to prevent cryptococcal meningitis. RECENT FINDINGS Cryptococcal antigen (CrAg) screening using a lateral flow assay platform is cost-effective and feasible to implement as either a laboratory reflex or point-of-care test. Recent CrAg screening pilots have elucidated the varying prevalence of cryptococcal antigenemia across geographic regions, which may aid programme planning. Evidence from recently completed clinical trials provides a strong motivation for the use of CrAg titer to refine treatment options for patients with subclinical cryptococcal disease. SUMMARY Although several operational barriers to programme effectiveness still need to be addressed, the utility of CrAg screening using inexpensive and accurate antigen assays has been demonstrated in real-world HIV programmes, paving the way for development and testing of other fungal opportunistic infection screening strategies and for an integrated advanced HIV disease testing package to reduce AIDS mortality and ensure safe antiretroviral treatment initiation.
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23
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Tonin FS, Steimbach LM, Borba HH, Sanches AC, Wiens A, Pontarolo R, Fernandez-Llimos F. Efficacy and safety of amphotericin B formulations: a network meta-analysis and a multicriteria decision analysis. J Pharm Pharmacol 2017; 69:1672-1683. [DOI: 10.1111/jphp.12802] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/17/2017] [Indexed: 01/25/2023]
Abstract
Abstract
Objectives
Despite its broad spectrum, conventional amphotericin B (AB) is associated with serious adverse events. Lipid-based formulations may offer safer options. We aimed to synthesize the evidence of efficacy and safety of AB formulations.
Methods
We performed a systematic review and network meta-analysis (NMA) to compare all available formulations: conventional AB; lipid complex or ABLC; colloidal dispersion or ABCD; liposomal or LAB; AB in Intralipid. Randomized controlled trials were searched in four databases. Cure, fever, chills, nephrotoxicity, death and drug discontinuation were assessed. NMA was based on Bayesian methods accounting for direct and indirect comparisons. Probability ranks estimating the best formulation were built for each outcome. The relative benefit–risk of formulations was assessed with stochastic multicriteria acceptability analyses (SMAA).
Key findings
We identified 25 trials (n = 2996). No significant differences among drugs were observed for cure or death. All lipid-based formulations were safer than conventional AB for nephrotoxicity. AB-Intralipid was more tolerable than conventional AB and caused less chills than ABCD. AB-Intralipid was the best therapy (>60%) regarding nephrotoxicity, fever, chills and discontinuation. The scenario from SMAA favoured AB-Intralipid (81% acceptability). Conventional AB was secondary to all lipid-based formulations.
Conclusions
Amphotericin B-Intralipid was identified as safer, cost-saving treatment in comparison with other formulations.
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Affiliation(s)
- Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - Laiza M Steimbach
- Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - Helena H Borba
- Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - Andreia C Sanches
- Department of Pharmacy, Universidade Estadual do Oeste do Paraná, Cascavel, Brazil
| | - Astrid Wiens
- Department of Pharmacy, Universidade Federal do Paraná, Curitiba, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Universidade Federal do Paraná, Curitiba, Brazil
| | - Fernando Fernandez-Llimos
- Department of Social Pharmacy, Faculty of Pharmacy, Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal
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24
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Armstrong-James D, Bicanic T, Brown GD, Hoving JC, Meintjes G, Nielsen K. AIDS-Related Mycoses: Current Progress in the Field and Future Priorities. Trends Microbiol 2017; 25:428-430. [PMID: 28454846 DOI: 10.1016/j.tim.2017.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/07/2017] [Accepted: 02/24/2017] [Indexed: 01/07/2023]
Abstract
Opportunistic fungal infections continue to take an unacceptably heavy toll on the most disadvantaged living with HIV-AIDS, and are a major driver for HIV-related deaths. At the second EMBO Workshop on AIDS-Related Mycoses, clinicians and scientists from around the world reported current progress and key priorities for improving outcomes from HIV-related mycoses.
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Affiliation(s)
- Darius Armstrong-James
- Fungal Pathogens Laboratory, National Heart and Lung Institute, Imperial College, London SW7 2AY, UK.
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London SW17 0RS3, UK
| | - Gordon D Brown
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa; MRC Centre for Medical Mycology, Aberdeen Fungal Group, University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Jennifer C Hoving
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota, 55455, USA
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Field Validation of SYBR Green- and TaqMan-Based Real-Time PCR Using Biopsy and Swab Samples To Diagnose American Tegumentary Leishmaniasis in an Area Where Leishmania (Viannia) braziliensis Is Endemic. J Clin Microbiol 2016; 55:526-534. [PMID: 27927916 DOI: 10.1128/jcm.01954-16] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/24/2016] [Indexed: 11/20/2022] Open
Abstract
The precise diagnosis of American tegumentary leishmaniasis (ATL) is an essential task due to the disease's associated morbidity. A noninvasive, extremely sensitive, and highly specific exam is critical, particularly for mucosal leishmaniasis (ML), in which a low parasite quantity is expected. We aimed to compare the diagnostic accuracy of swab and biopsy sample analysis using SYBR Green- and TaqMan-based real-time PCR (qPCR) assays with that of a composite reference standard consisting of the Montenegro skin test, serology, histopathology, smears, culture, and conventional PCR. In total, 55 patients with ATL (ML, 18 patients; cutaneous leishmaniasis [CL], 37 patients) and 36 patients without ATL were studied. qPCR analysis of swabs was more accurate when using SYBR Green (87.88%; 95% confidence interval [CI], 77.86 to 93.73 patients) than when using TaqMan (78.79%; 95% CI, 67.49 to 86.92%) (P = 0.031). SYBR Green (84.72%; 95% CI, 74.68 to 91.25%) was also more accurate than TaqMan (73.61%; 95% CI, 62.42 to 82.41%) for biopsy samples (P = 0.008). All qPCR methods were 100% specific. Swabs and biopsy specimens had similar sensitivity when using the same chemistry (P = 0.125 for SYBR Green and P = 0.625 for TaqMan). Moreover, qPCR achieved better performance than most existing techniques used for the diagnosis of ATL and also detected the Leishmania parasite in a greater proportion of patients than the associated histopathology, smear, culture, and conventional PCR techniques did. Swabs therefore represent a useful diagnostic tool because they not only are noninvasive but also can achieve an accuracy similar to that of biopsy samples. The high accuracy of SYBR Green-based qPCR may also reduce the requirement for associated parasitological tests for ATL diagnosis.
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